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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA No <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Loco{ Health District. , <br /> _Q?3o2� ����N�u�— X/��Lot Sire � `AC dad PM <br /> C ityr <br /> \Job Address <br /> Phonetf� <br /> wner's Name � Address ��� - <br /> xGontractor Address_ 3. n Ertl License No. <br /> Phone <br /> U <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJDESTRCTION LJ <br /> PUMP INSTALLATION SYSTEM R R ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION GRICULTURE WE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CO TRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca D' . of Well Excavation Specifications <br /> ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy of Casing <br /> M Public <br /> Cl Other C i Delta Depth o out Seal Type of Grout <br /> _ <br /> i I Irrigation Depth l I Eastern Surface Seal Ins by <br /> Repair Work Done L7 Type of Pump <br /> H Sta Work Done_ <br /> Well Destruction ❑ Well Diameter ealing Material (top 501 <br /> Depth Filler Material (Below 50'i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAISIADDITION I I DESTRUCTIO (o septic <br /> system thin 200 feeftMed if public sewer is <br /> installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> d that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application an <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ-any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Califor <br /> The applicant st call to all required ctions. omplete drawing on reverse side. -- -- JJ <br /> igned X Title:.�K�L A=LL Date: <br /> F DEPARTMENT USE ONLY <br /> Date b— Area <br /> Application Accepted by ' <br /> Pit or Grout Inspection by <br /> Data Fina! Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> !FEE RECEIVED BY DATE PERMITNO. <br /> AMOUNT DUE AMOUNT REMITTER 7 <br /> + EH 13-24 TREY.1/A al �� i�r 17 v' EZ <br /> EH 14-26 <br />